EMPHNET Meeting (Sharm Elsheikh, Dec. 5, 2011)
Ghaiath M. A. Hussein
Assistant Professor of Bioethics
Faulty of medicine, King Fahad Medical City
Riyadh, Saudi Arabia
Email: ghaiathme@gmail.com
Phone: 00966566511653

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Public health (vs. clinical care)
What’s Ethics? What is Public Health Ethics
(PHE)?
Sources of ethical concern in public health practice and research
Why are pandemics ethically unique?
Levels of pandemic effects and their ethical implications
Guiding ethical principles
How to deal with ethical tensions in PH?

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Definitions:
 “Public health is what we, as a society, do collectively to assure the conditions for people to be healthy.” (IOM, 1988);
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 "Public health is primarily concerned with the health of the entire
population“ (Childress et al.)
Scope: health promotion and disease prevention throughout society )
Fields: Policy; Practice; and Research
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“the process of mobilizing and engaging local, regional, national and
international resources to assure the conditions in which people can be healthy” (Oxford Textbook of public health, 2004 )
Disease prevention
Health promotion
Epidemiological studies
Biostatistics
Occupational health
Environmental health
Determinants of health
WSH

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Morality & Ethics:
 Morality: the beliefs and standards of good and bad, right and wrong, that people actually do and should follow in a society, while ethics is defined as the systematic study of morality.
Metaethics: tries to clarify the rational standards and methods for the study of ethics
Normative ethics: develops ethical principles, rules, and ideals that spell out standards of good and bad, right and wrong.

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Bioethics: is normative ethics applied to decisionmaking and public policy in the domains of biology, health care and research.
Domains:
Clinical/medical ethics
Research ethics
Public health ethics
Environmental ethics
Resource allocation ethics
Organizational ethics, etc.
Public Health Ethics (PHE): the identification, analysis, and resolution of ethical problems arising in public health practice and research

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Within its efforts to control the spread of
Pandemic Influenza A H1N1 during the Hajj season (2010), the Saudi government was able to provide a total of 2,500,000 doses of the newly produced vaccine.
The pilgrims are estimated to be 3,500,000; the working staff who are in contact with pilgrims (entries, security & health) are about
120,000 persons
Who should have the vaccine? Who’s first?

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Public vs. individual rights
Scarcity of resources
Socio-political factors:
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Poverty, illiteracy , minorities, vulnerability
 Abuse of power (public engagement)
Socio-cultural factors:
Local beliefs vs. “international guidelines”
 Role of families and community leaders
Urgency to contain public health threats
Inequalities (national and international)

Disproportional burden
COI (®Tamiflu, vaccine)
Resource allocation
Consent
Public engagement
Sub-optimal products
Surveillance
(research?)
Inequalities
Trials (review)
Loss of property
&work hours
Access to care
Restricted movement
Confiden tiality
Professiona l duty

Philosophical
• Deontological
• Utilitarian (act & rule)
• Rights-based
• Virtue
• Casuistry
• Social-contract
• Principlism
Religious
• Islamic ethics & jurisprudence
(Purposes of Law
‘Sharia’)
• Christian ethics
Guiding Principles
• Utility
• Efficiency
• Liberty
• Transparency
• Participation
• Review and revisability
• Effectiveness
• Fairness
• Reciprocity
• Solidarity

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Deontology and principilism:
 Deontology is duty-based, people should act so as to fulfill their duties to others; acts should always follow a set of maxims (e.g. do not lie); and less concerned with the act’s consequences.
 Principilism is one way of approaching professional deontology
Examples:
 Hippocrates’ oath (“First, do no harm” or “Primum non nocere”)
 Belmont Report, produced in 1978 (three principles)
 Beauchamp and Childress in 2001 (four principles—beneficence, nonmaleficence, respect for persons, and justice )
Rights-based ethics: involves a larger number of principles and is addressed more to the actions of institutions and governments, e.g.
Universal Declaration on Bioethics and Human Rights, (UNESCO) in
October 2005. It provides more binding legal rights

 Consequentialism (utilitarianism)
 the right action is that which produces the greatest sum of pleasure in the relevant population,
• Act utilitarianism: a person should act in the way
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Rule utilitarianism: looks at the consequences of general rules instead of the consequences of individual acts

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Utility: acting so as to produce the greatest good.
Efficiency: calls for minimizing the resources needed to produce a particular result or maximizing the result that can be produced from a particular set of resources.
Liberty: one should impose the least burden on personal self-determination that is necessary to achieve a legitimate goal
Fairness: “treating like cases alike”
Reciprocity: individuals (professionals) accept of the risk in executing their duties would engender reciprocal duties on the part of the community to them
Proportionality: actions taken proportional to need

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If we can not agree on what’s fair distribution, let’s at least agree on a procedural justice (fair process).
“Fair process”
(Norman Daniels’ A4R) suggests a set of principles that need to be followed in decision making:
 Transparency/publicity: information about the processes and bases of decisions should be made available to the affected population
 Participation: the stakeholders should be involved in the processes of formulating the objectives and adopting the policies.
 Effectiveness/Relevance: states that there must be ways to translate the other principles into practice relevant to meeting population health needs fairly
 Appeal: Stakeholders should have a way to appeal policies after they have been adopted, and processes should be in place that allow policies and plans to be reviewed and revised.

Research or
‘practice’?
Research
Practice
Urgent
Not urgent
Ethics considered?
Fast track review
Prior approval
RECs
Implement policy
Add ethical considerations

Source of tension Suggested ethical/practical approach
Differences in guiding references/principles
Scarcity of resources -Develop a fair decision-making process
-Prior priority setting standards & guidance
Urgency
-Local (national) deliberation
-Regional meetings
-Unifying/Uniforming int’l ethical guidance to include local sources
-Prior planning
-‘Ethical drills’
-‘Fast track’ review mechanism
-On-call ethicist

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Proactive ethical preparedness, learning from past experiences (SARS, H5N1, and H1N1)
Involvement of ethics in the PH policy development process
Active public engagement
Develop an ethics comprehensive and flexible consultation and review mechanism
International (UN) agencies should advocate for the least powerful nations (Fair international governance)
Though agreeing on the guiding principles to make a fair decision is difficult; it is possible to agree on a fair decision making process
Make sure the voice of the voiceless is heard!

Feel free to contact:
Ghaiath Hussein
Assistant Professor of Bioethics
Faulty of medicine, King Fahad
Medical City
Riyadh, Saudi Arabia
Email: ghaiathme@gmail.com
Phone: 00966566511653

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Principles of the Ethical Practice of Public Health; Public Health
Leadership Society (2002)
Ethics and Public Health: Model Curriculum. Ed. Bruce Jennings et al. (2003)
Childress JF, Faden RR, Gaare RD, Gostin LO, Kahn J, Bonnie RJ,
Kass NE, Mastroianni AC, Moreno JD, Nieburg P: Public health
ethics: mapping the terrain. J Law Med Ethics 2002, 30:170-8.
Public health: disconnections between policy, practice and
research. Jansen et al. Health Research Policy and Systems 2010,
8:37
Ethical issues in epidemiologic research and public health
practice. Steven S Coughlin. Emerging Themes in Epidemiology
2006, 3:16
Accountability for reasonableness. Norman Daniels, BMJ
2000;321:1300-1301